Anesthetics

Question 1

What is monitored anesthesia care?

Answer 1

Using sedatives and other agents, but the dose is low enough that the patient remains responsive and able to breath without assistance. We use this for simple procedures and minor surgery. MAC generally refers to IV sedation.

Question 2

What is the main difference between MAC and GA?

Answer 2

Patients in GA no longer respond to stimuli

Question 3

Define minimal, moderate, and deep sedation, and general anesthesia

Answer 3

Minimal Sedation (Anxiolysis)- Pt responds normally to verbal commands. Cognitive function and coordination may be impaired. Vent and CV function unaffected.

Moderate Sedation (Conscious sedation)- responds purposefully to verbal commands alone or with light tactile stimulation. Airway and ventilation are fine. CV usually fine.

Deep- Not easily aroused. Responds purposefully to repeated/painful stimuli. Ventilation and airway may be impaired. CV usually fine.

GA- Not arousable even by painful stimuli. Needs assistance with patent airway, may need PPV. CV may be impaired.

Question 4

Effects of general anesthesia

Answer 4

No sensory perception
Loss of consciousness
No recall of events
Immobility

Others include muscle relaxation (although you don’t NEED muscle relaxants), suppression of the ANS, analgesia, and anxiolysis.

Question 5

What is the only anesthetic that has analgesic properties?

Answer 5

Ketamine. Our other anesthetics just cause loss of consciousness.

Question 6

General induction sequence

Answer 6

Pre-op meds (anxiolytic, antibiotic, etc)
Induction agent
Paralytic
Maintenance agent
Opoids
Antiemetics
Reversal agents (reversal of the paralytic)

Question 7

Why do we need to give antiemetics?

Answer 7

Because the opioids and anesthetics can cause nausea

Question 8

5 effects of benzodiazepines

Answer 8

ASAAM

1) Anxiolysis
2) Sedation
3) Antegrade amnesia
4) Anticonvulsant
5) Muscle relaxation (at the spinal level)

Question 9

Prototype for benzos

Answer 9

Diazepam (Valium)

Question 10

Midazolam (Versed) is an example of this class of drugs)

Answer 10

Benzos

Question 11

How do benzodiazepines work?

Answer 11

Potentiating the binding of GABA to GABAa receptors and increases the potency of GABA x 3.
Causes Cl- influx, hyperpolarizing the cell and decreasing its excitability

Question 12

When would benzos drop your BP?

Answer 12

When used in large doses for induction (due to a decrease in SVR), especially with hypovolemia. Also may decrease because the pt was anxious before and is now more relaxed.

Question 13

When are benzos contraindicated?

Answer 13

Pregnancy

Question 14

What do opioids bind to?

Answer 14

On Mu receptors which can be located on either the pre or post-synaptic membranes

Question 15

At what anatomical locations do opioids work?

Answer 15

In the brainstem, spinal cord, and peripheral tissues

Question 16

Opioids result in decreased release of this NT

Answer 16

Substance P

Question 17

Why should we try to avoid a benzo/opioid cocktail pre-operatively?

Answer 17

They have a synergistic effect on ventilation

Question 18

What is the benefit of using opioids for general anesthesia?

Answer 18

It doesn’t drop BP (although it will cause bradycardia!)

Question 19

How much fentanyl would be needed to induce GA?

Answer 19

50-100mcg/kg

Question 20

This class of drugs are the classic induction agents

Answer 20

Barbiturates. Because the end result is depressing the reticular activating system (causing sleep).

Question 21

Which are more effective as anticonvulsants, benzos or barbiturates?

Answer 21

Barbiturates

Question 22

Which class of medications, when injected arterially, will cause gangrene and nerve damage?

Answer 22

Barbiturates

Question 23

What can cause enzyme induction?

Answer 23

Smoking, ETOH, and barbiturates.

Question 24

What barbiturate is the most potent enzyme inducer?

Answer 24

Phenobarbital

Question 25

What's the deal with barbiturate allergies?

Answer 25

It's very rare (1:30,000), but highly fatal

Question 26

Barbiturates increase the metabolism of these drugs

Answer 26

Oral anticoagulants, phenytoin, TCAs, corticosteroids, and Vitamin K

Question 27

Barbiturates should be avoided in patients with

Answer 27

Porphyria. Barbs cause rapid heme production through the stimulation of the enzyme D-aminolevulinic acid synthetase. People with porphyria have shitty heme. So if you give benzos to these people, they will have a shit ton of shitty heme.

Question 28

Do barbiturates cross the placenta?

Answer 28

Yes.

Question 29

Barbiturates stimulate this enzyme responsible for heme production

Answer 29

D-aminolevulinic acid synthetase

Question 30

What is included in the base of propofol?

Answer 30

Egg, soy, and glycerol

Question 31

Bronchoconstriction is often related to what?

Answer 31

Patient not being deep enough. Asthmatics are at an even higher risk of this if they are not deep enough. You want asthmatics to be very deep because they are at high risk of bronchoconstriction when stimulated.

Question 32

Can propofol be given to those with egg allergies?

Answer 32

Yes

Question 33

This medication attaches to the B1 subunit of the GABAa receptor

Answer 33

Propofol

Question 34

Succinylcholine binds to what type of receptors?

Answer 34

Nicotinic ACh receptors

Question 35

Succinylcholine is often replaced with

Answer 35

Rocuronium

Question 36

How can we reduce myalgias with succ?

Answer 36

Give a small dose of a non-depolarizing agent first, and then give the succ

Question 37

If giving succ to kids, what should you also give them and why?

Answer 37

Give atropine. Succ blocks ACh receptors, which can cause profound bradycardia in kids.

Question 38

This medication is a POTENT trigger of malignant hyperthermia

Answer 38

Succinylcholine. Isoflurane can also trigger MH.

Question 39

Succ should be avoided in

Answer 39

Patients with atypical acetylcholinesterase. Remember this is familial, so if the patient describes a family member not waking up after surgery, etc., then don't draw this up as an emergency medication.

Question 40

Patients with these diseases are at higher risk for hyperkalemia when given succ

Answer 40

Burns, trauma, nerve damage, neuromuscular diseases, and renal failure. `

Question 41

Prototype for the non-depolarizing muscle relaxants

Answer 41

Vecuronium

Question 42

Structure of vecuronium

Answer 42

Monoquarternary aminosteroid

Question 43

What receptors does vecuronium work on?

Answer 43

Pre and post-synaptic nACh receptors

Question 44

For what patients will vecuronium not work?

Answer 44

Burn patients

Question 45

Things to look out for with vecuronium

Answer 45

Residual NM blockage and increased likelihood of recall

Question 46

How are inhalational anesthetics eliminated?

Answer 46

Via the lungs. We can alter elimination by varying the RR. Liver and kidney disease won't affect metabolism or elimination.

Question 47

What is usually the only inhalational anesthetic used for induction?

Answer 47

Sevoflurane

Question 48

Do inhalational anesthetics act as a bronchodilator or constrictor?

Answer 48

Bronchodilator

Question 49

What is the MAC of an anesthetic?

Answer 49

The alveolar concentration of an inhalational agent at which 50% of patient will not move to a noxious stimulus

Question 50

What is the only inhalational agent we used that will not provide anesthesia by itself?

Answer 50

Nitrous oxide (N2O)

Question 51

Local anesthetics will block APs ONLY if the Na channels are in this state

Answer 51

Inactivated-closed

Question 52

If your patient starts having signs of local anesthetic toxicity, you should give them this

Answer 52

Versed (because the patient will probably have a seizure)

Question 53

Local anesthetic with high risk for cardiac toxicity

Answer 53

Bupivicaine (can cause arrythmias, AV blocks, hypotension, and arrest)

Question 54

What class of drug would you want to give to induce anesthesia in a patient with high ICP?

Answer 54

Barbiturates